Provider Demographics
NPI:1952431678
Name:KENNEDY, THERESA WAGNER (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:WAGNER
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1667
Mailing Address - Street 2:
Mailing Address - City:OAKHURST
Mailing Address - State:CA
Mailing Address - Zip Code:93644
Mailing Address - Country:US
Mailing Address - Phone:559-683-3657
Mailing Address - Fax:559-642-0673
Practice Address - Street 1:40459 HWY 41
Practice Address - Street 2:STE 5
Practice Address - City:OAKHURST
Practice Address - State:CA
Practice Address - Zip Code:93644
Practice Address - Country:US
Practice Address - Phone:559-683-3657
Practice Address - Fax:559-642-0673
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS10602103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist